male infertility and impotence. definition infertility is “inability to conceive after one year of...
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Male Infertility and Impotence
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Definition Infertility is “inability to conceive after
one year of conjugal life without use of contraceptive methods.”
The term "primary infertility" is applied to “the couple who has never achieved a pregnancy.”
"secondary infertility" implies that “at least one previous conception has taken place.”
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origin of problem: 35% female 35% male 20% both partners 10% unexplained
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Major Causes
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Etiology of Male InfertilityMulti-factorial Prevalence Varicocele 35% Idiopathic 25% Infection/injury – genito-urinary tract 10% Genetic/systemic disease 10% Endocrine 1 - 5% Immunologic 1 - 5% Obstruction 1 - 5% Developmental 1 - 5% Lifestyle: smoking, diet, heat ???%
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Aetiological Classification 1.Disorders of spermatogenesis: A)Hormanal Hypothalamic disorder Pituitary secretion of FHS and LH Hyperprolactinaemia causing Impotence or
diminished libido. B) Primary testicular disorders: Idiopathic, Varicocele Chromosomal defect, i.e. klinefilter’s syndrome Crytorchism
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Drugs,radiations Orchitis (traumatic,mumps, TB,gonorrhoea) Chronic illness Immunological disorders . 2) Duct obstruction: Congenital absence, inflammatory block, surgical
trauma, 3)Accessory glands disorders:Prostitis, vasiculitis,
congenital absence of vas in cystic fibrosis.
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4.Disorders of sperms and vesicular fluid: Sperms antibodies and low fructose in seminal plasma.
Sperms acrosome defect Zona pellucida binding defect Zona penetrations defect Oocyte fusion defect 5. Sexual dysfunctions: Low frequency coitus- wrong time Impotence, hypospadias Premature Ejaculation, retrograte ejaculation
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6.Psychological factors and environmental factors like smoking,alcohol consumption,tobacco chewing,diabetes,
Drugs: antihypertensive,antipsycotis,sex steroids, chemotherapy, beta-blockers, spirolactone,oestrogen
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Female Infertility EtiologiesUnexplained
Cervical/mucus
Endometrial/uterine
Pelvic/peritoneal
Tubal
Developmental/genetic
10% 2-3% 2-3% 5-10% 30-50% 40%
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Other Etiologies PID Cx conization/cautery Smoking IUD Endometriosis Genetics
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Aetiology 1.dyspareunia and vaginal causes 2.Congenital defect in the genital tract. 3.infection in the lower genital tract. 4.Cervical factors 5.Uterine causes 6.Tubal factors 7.Ovaries 8.Peritoneal causes 9.Chronic ill health – especially thyroid
dysfuntion
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The Most Important Factor in the Evaluation of the Infertile Couple Is:
HISTORY
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History-General Both couples should be present Age Previous pregnancies by each partner Length of time without pregnancy Sexual history Frequency and timing of intercourse Use of lubricants Impotence, anorgasmia, dyspareunia Contraceptive history
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Male Infertility: Evaluation History (Questionnaire) Physical examination Standard semen analysis Hormonal evaluation Genetic counseling and evaluation Imaging studies
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History-Male History of pelvic infection Radiation, toxic exposures (include
drugs) Mumps Testicular surgery/injury Excessive heat exposure
(spermicidal)
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Physical Exam-Male Size of testicles Testicular descent Varicocoele Outflow abnormalities
(hypospadias, etc)
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Male Factors-Semen Analysis Collected after 3 days of
abstinence Evaluated within one hour of
ejaculation If abnormal parameters, repeat
twice, 2 weeks apart
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Semen Analysis:World Health Organization Guidelines
Parameters Normal range Volume 1.5 - 5 mLSperm conc. >20 million/mLSperm motility >50%Sperm morphology >30% normal formsLeukocyte density <1 million/mL
Need at least 2 S/As
Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculateMale should be abstinent for 48 to 72 hours
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Semen Analysis
Abnormal semen results Azospermia Oligospermia Athenospermia Teratospermia
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Sperm Terms Normozoospermia Normal ejaculate
Asthenozoospermia
Teratozoospermia
Azoospermia
Aspermia
Normal ejaculate Sperm concentration
<20 × 106 /ml <50% spermatozoa
with forward progression
<30% spermatozoa with normal morphology
No spermatozoa in the ejaculate
No ejaculate
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Hormonal and others GnRH FSH LH TSH Prolactin level
Rule out genetic diseases.
Chromosomal study
Immunological study
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Imaging Studies Transrectal Ultrasound (TRUS) Vasography Testis Biopsy
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Transrectal Ultrasound (TRUS)
Seminal vesicle dilatation.
Ejaculator ductal stones
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Vasography Indication
Assessment of vasal obstruction or ejaculatory duct obstruction.
An inguinal vasal obstruction should be suspected in an azoospermic patient with normal spermatogenesis and a history of prior inguinal or scrotal surgery.
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Testis Biopsy Indication
Distinguishing between obstruction and testicular failure.
Identification of mature sperm for ICSI
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Treatment- Male Factor Hypogonadotrophism:-GnRH Ligation Retrograde ejaculation Testosterone for spermatogenesis Clomiphene 50 mg daily for 3 months for
oligospermia. Empierical medical therapy by administration of
vit.c , B 12, folic acid. Varicocele:- surgical treatment Obstruction:-short-cut operation IVF/IUI :- last option.
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Female Infertility: Evaluation History (Questionnaire) Physical examination Ovarian factor Tubal factors Hormonal analysis Immunological test Postcoital test
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History-Female Previous female pelvic surgery PID/Infection Medical diseases:-TB, diabetes,STD IUD use/MR done Ectopic pregnancy history Proven fertility Endometriosis
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History-Female Irregular menses, amenorrhea,
detailed menstrual history Vasomotor symptoms Stress Weight changes Exercise Cervical and uterine surgery
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Physical Exam-Female Pelvic masses Uterosacral nodularity Abdominopelvic tenderness Uterine enlargement Thyroid exam Uterine mobility Cervical abnormalities
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Ovarian factors Fern test Endometrial biopsy in secretory
phase Serial USG Serum progesterone Laparoscopy D & C.
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Tubal factor
Tubal patency test by:-
Tubal insufflation test Hystero-salphingo-graphy Laproscopy dye insufflation test Hydrotubation
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Hormonal Immunological FSH LH Estrogen Progesterone TSH Prolactin Testosterone
Antisperm antibody
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Treatment for female factor
Anovular :- clomiphene citrate bromocriptine
D&C:- histopathology, bacteriology Reconstructive surgery:- developmental
defect Surgery:- tubal block If all method fails, then go for….
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Assisted Reproductive Technologies
Intrauterine Insemination(IUI) In Vitro Fertilization(IVF) IVF and Intra Cytoplasmic Injection of S
perms(ICSI)
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Intrauterine insemination (artificial insemination)
•definition: Artificial introduction of semen into the vagina, cervix or uterus by means other than coitus to produce pregnancy is called artificial insemination.
•sperm can come from husband or donor or pool donor.
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IUI, cont’d. 6000 babies / year born in US. as result of
artificial insemination
INDICATION OF ARTIFICIAL INSEMINATION:-
1. Impotent husband.2. Sterile husband.3. Husband suffering from hereditary disease.4. Rh-incompatibility between husband and wife.
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In vitro fertilization test - tube babies” 1st performed in 1978 (Louise Joy
Brown) often performed on infertile
women with tubal blockage
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Test tube babies/ in-vitro fertilization
Techniques:-I. The ovum is removed from ovary through
abdominal wall and is fertilized with the sperm in a small laboratory dish in artificial medium..
II. At the stage of blastocyst, the embryo is return to uterus through cervix.
III. Blastocyst is implanted in endometrium.
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Artificial insemination in laboratory disc
Blastocyst